Harry was 75-years-old, with heart disease, leg ulcers, and mental confusion. He lived with Violet; their relationship was never clear to me, but she cared for him, and received his Social Security check to help her do so. She lived in a drafty old house with three big dogs — and Harry.
As his visiting nurse, I often found Harry naked in a filthy bed, with dog feces on the floor, and his urinary catheter pulled out. Violet was belligerent and unwilling to talk with me about how to care for Harry.
I had other patients all over the North Side of Chicago with worse medical problems than Harry; yet I visited him multiple times weekly to address the health risks in his living situation. Harry didn’t need more doctors or medicine. Harry needed someone to address his living conditions — the often overlooked social determinants of health.
Factors such as income, education, employment, social support from family and friends, and community safety are what we call social determinants of health. They greatly impact a person’s health, and yet are rarely addressed effectively by doctors and nurses in a traditional setting.
Social and economic factors are responsible for 40 percent of health outcomes, and physical environment (air and water quality and housing) is responsible for another 10 percent, according to the 2016 County Health Rankings. This means that nearly half of what makes people healthy or sick is not related to medical care. Where a person lives — his or her zip code — is a better predictor of overall health than whether or not the individual has access to medical care.
Other developed countries around the world have better health outcomes for their populations than the U.S. According to the National Academy of Sciences, this is due, in part, to their more robust social safety nets. In other words, they have better programs to address the social determinants of health.
As the U.S. debates how to improve health outcomes for its entire population, and urgent public health crises emerge following the hurricanes affecting Florida, Texas, and Puerto Rico, we see that access to care is only part of the solution. We also need to support models of care with demonstrated success at addressing all the factors that cause illness.
The American Hospital Association recently released recommended strategies for providers to address the social determinants of health, including being able to screen clients, help them navigate referrals and services in the social service sector, and work collaboratively to align services with client needs.
My job required me to visit Harry in his home, where I could see firsthand his living conditions and talk to both him and Violet. When I couldn’t help Violet to better care for him — due to her own mental health problems — I was able to bring in the needed resources to get Harry placed in a better living situation. And he was.
As a nurse, I could speak to what he needed for health care, and what he needed for daily living. I could address the social determinants of health in his case in a way many other health professionals could not. This has long been what nurses who worked in public health or as home care nurses have done.
The most recent federal survey of nursing employment shows that out of 2.7 million registered nurses, only 37 percent work outside of hospitals. This is predicted to change dramatically in the near future as insurers and the government begin to pay for value-based care, that is, care based on health outcomes achieved, rather than specific services provided.
These new models of care can look at cost effective ways to achieve healthier outcomes for people. Because of their numbers and education, nurses need to be integral to these efforts. That is because nurses work across all aspects of the healthcare continuum — from hospitals to community. Nurses can work with patients in the hospital to ensure that they have a safe place to go when discharged. Nurses can then follow up with care in the home, to make sure elderly or fragile clients are safe and receiving the medications they need, as I did with Harry.
Nurses — like doctors — see patients in clinics to ensure that clients understand their health problems and how to manage them. Nurses also work with children in schools to ensure that they are safe, have a care provider, and are fed adequately. At every place in people’s lives where their health can be impacted by social and environmental conditions, nurses are there with both the clinical skills and educational background to address the clients’ health and social needs. Yet more can be done.
Some health care organizations are looking at ways to use big data to assess the social determinants of health in patients, and then help providers access and use this information to improve health outcomes.
Nurses will be key in helping to meet the national goals for addressing the social determinants of health found in Healthy People 2020. Of the 25 measurable goals set by the Centers for Disease Control, 40 percent showed no progress at the midterm assessment in 2015. These included goals related to helping people get needed social support, protecting children from violence, ensuring safe housing, addressing food insecurity in the home, and ensuring that people have access to a provider who effectively teaches them how to manage their health.
To change that, nurses are in the best positions to address these social determinants of health and improve health outcomes. The American Nurses Association defines nursing as “the protection, promotion, and optimization of health and abilities, prevention of illness and injury, facilitation of healing, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, groups, communities, and populations.”
Working to promote and protect health for individuals and communities, nurses have long been considered as part of the most trusted profession, according to the annual Gallup polls. They also make up the largest group of health care professionals.
Public health professionals and social workers can also be helpful in this area and are valued partners in this work. However, they do not have training in both the social and medical fields. Bringing together clinical health knowledge and skills with a focus on health promotion, disease prevention and advocacy, nurses offer the perfect prescription for changing health outcomes.
Yet, while some nurses do focus on the social determinants of health, these factors are often not stressed in the curriculum of their education, nor is this training assessed on state licensure exams. That needs to change.
In nursing education, curriculum expansion is needed to ensure that all nurses come into the field with measurable knowledge and skills in population health. Current RNs can be provided with the opportunity to gain this knowledge and skills through continuing education.
Only then will we see healthier communities and a healthier nation.
For Harry, this meant that I went to court to have him declared a ward of the state, allowing his removal from Violet’s home and his move to a safer environment where he was far better off.